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AOAAppliances, etc.
Thinking
Appliances…
Thanks for making our inaugural AOA Appliances,
etc. newsletter an instant success – the feedback
we have received from our first issue has been
overwhelming. Our goal is to continue to share
with the profession new appliance designs, clinical
applications, practice pearls and other related
laboratory information. Your participation is greatly
appreciated.
With our second issue, we are pleased to introduce
Dr. Robert Workinger of Marshfield, Wisconsin,
writing on cleft palate treatment utilizing Bonded
Rapid Palatal Expansion Appliances. We are
also delighted to introduce Dr. Larry Gaston,
Hazelwood, Missouri, with his article on Modified
Spring Retainers for post-treatment retention.
In addition, we have included an article on
Pre-treatment Diagnostic Set-ups and their value
as a visual aid when consulting with your parents
and patients. Finally, we have an update on the
MARA Appliance and the overwhelming interest
in this new appliance design, as well as an article
from Dr. Jim Hilgers, Mission Viejo, California, on
his new PhD Appliance.
These articles continue to demonstrate our commitment to share with the profession innovations
and appliance news. Please remember to simply
pick up the telephone and contact me, personally,
to share any ideas you employ in your practice.
I always look forward to hearing from you.
David Allesee
General Manager,
AOA Laboratory
AOA allesee orthodontic appliances
In partnership with your practice
VolUME 2, number 1, 1998
Cleft Palate –
A Case Report
by Dr. Robert Workinger
Marshfield, Wisconson
This patient is a 9 year-old Caucasian male referred to me by an oral and maxillofacial surgeon. The parents and patient presented with a chief concern of, “He was
born with the cleft lip and palate and his teeth are not straight” (Figures 1 and 3).
The patient’s past medical history was essentially normal except for a complete
unilateral right cleft lip and palate. Tonsils and adenoid had not been removed. The
clefts of the lip, soft and hard palates, had been previously closed. Speech correction
had been recommended.
Cephalometric evaluation
revealed a nine year old
adolescent with a skeletal
age of 7.8 years; growth to
maturity 75% complete.
He had an Angle Class II
dental relationship and a
mesocephalic Class II
skeletal pattern due to
both mandible and palate.
There was a tendency
toward a skeletal open bite
due to both maxilla and
mandible; the palatal
plane was superiorly tipped
4.7 degrees relative to the
Frankfort Horizontal
Plane. The patient had a
skeletal lingual crossbite
due to both maxilla and
mandible.
The panoramic radiograph showed normal development of all permanent premolars,
and first and second molars; third molars were not evident. The maxillary right
continued on following page
Workinger
continued from preceding page
cuspid, and the maxillary left and right permanent lateral incisors were
congenitally absent. Two supernumerary teeth were present in the cleft
site, as well as a residual maxillary left permanent lateral incisor which
was nothing more than a mass of enamel embedded in the alveolus.
into the buccal surfaces of the Bonded RPE appliance provided
anchorage for a series of upper archwires (Figure 4). In due time,
plastic pontics with attached brackets were tied to the archwire to provide esthetic replacement of the missing cuspid and lateral incisors.
Since the root of the maxillary left cuspid was 50% developed, the
surgeon felt that timing was appropriate for the palatal expansion to
prepare the patient for surgery. The proposed surgical plan was mucosal
pedicle graft over the alveolar defect. An autologous bone graft from
the hip would be used to close the oronasal fistula, create a new nasal
floor, and provide alveolar bone for eruption of the permanent cuspid.
It is important to note that the fixed expansion appliance was left in
place for nine months following surgery – much longer than would be
necessary in a non-cleft patient. This was necessary both to obtain
maximum post-surgical healing and to facilitate regeneration of
alveolar bone in the cleft site.
Both the greater and lesser alveolar segments of the maxilla showed
almost equal amounts of lingual collapse. Therefore, orthodontic
treatment was initiated using a Bonded Acrylic Palatal Expansion
Appliance with occlusal coverage of the posterior dentition. The transverse palatal screw was activated by a parent once a day (1/4 revolution
per activation) until significant over expansion was achieved (Figure 2).
Following stabilization of the palatal screw, brackets were bonded to the
maxillary central incisors. Rectangular tubes previously incorporated
Fixed stabilization, such as a trans-palatal arch or a quad-helix, is
usually recommended in this type of case. However, the patient and his
parents proved extremely cooperative. This, and the need to optimize
anterior esthetics, led to the choice of a Hawley type retainer with cuspid and lateral incisor points for intermediate stabilization (Figure 5).
The patient will now be followed on a regular recall basis until such
time as definitive orthodontic treatment is indicated, with or without
additional orthognathic surgery. Fixed prosthetic services will be the
final stage of the overall treatment plan.
Figure 2
Figure 1
Figure 3
Figure 4
Figure 5
PRE-TREATMENT
DIAGNOSTIC
SET-UPS
T
he diagnostic set-up has been used by orthodontists for many
years to aid in treatment objectives as well as a method of presenting treatment options and potential results to patients. The
most common request or issue is whether to extract permanent
teeth or treat non-extraction. Often times adults present with
crowding of the anterior teeth as their chief complaint. The orthodontist might have several options to explore, including first bicuspid
extractions, lower incisor extraction or interproximal reduction (stripping) to name a few. On occasion, combinations of the above scenarios
are applied. Another interesting application of the diagnostic set-up is
the joint or mixed dental team treatment approach with the use of traditional crown and bridge restoration, and now implants, in conjunction with orthodontics.
ized. If crown and bridge or implants are to be used in the treatment,
just indicate the location and representative plaster pontics will be
added to the set-up. If there is to be a surgical element to the treatment, for instance, a mandibular advancement, a wax shim will be
added to the heel of the lower set-up model giving some perspective
of the advancement.
The principle goal is to map out a successful treatment plan. However,
the selling of the goal with the addition of a diagnostic set-up to the
sophisticated patient should not be overlooked.
The requirements for having a diagnostic set fabricated by AOA are:
1) A quality model in either stone or plaster. The bases should be
trimmed in centric occlusion and in scale to present an attractive setup to the patient and referring or consulting dentist. If the models are
to be preserved, please indicate on the Rx form that a duplicate model
is to be used. This is our normal procedure. AOA will duplicate your
casts for the purpose of constructing the set-up. 2) Indicate which
teeth are to be reset. If, for instance, the upper and lower molars are in
good occlusion and the treatment plan is to unravel crowded anterior
teeth, the molars can remain unreset. Often, by leaving “landmark”
teeth in this manner, a better or more practical result can be visual-
Modified Spring Retainer
Post-Treatment Retention
by Dr. Larry Gaston
Hazelwood, Missouri
O
occasionally observed a severe relapse of the teeth which necessitated
the use of two appliances: first, partial resetting of the teeth and a
new appliance followed by full resetting of the teeth and a second
retainer to complete and hold the correction. Spring retainers have
allowed us to avoid returning to fixed appliances to correct a relapse
or to treat adult patients needing only minor tooth movement.
We appreciate these retainers for their durability as well as their
flexibility and the fact that they are removable offers the advantage
of improved oral hygiene when compared to bonded retainers.
ur patients, both adolescent and adult, are subject to the
same human behavior and sometimes fail to wear their
retainers with enough consistency to maintain correct
alignment.
We have used modified Hawley/spring
retainers for twenty years. In my hands,
the traditional Hawley retainer was too
rigid to effectively or comfortably restore
alignment or correct all but the most
minor rotational relapse of anterior teeth.
The spring retainer worn full time for
a few days or weeks will correct fairly
severe rotational relapse or misalignment.
Following the loss of a retainer, I have
Mushroom Modified Spring Retainer
IT’S A GOOD THING
MARA Update
AOA on the Road
Our entire team will be attending the AAO
Meeting in Dallas, May 14-20, 1998. If you
are planning on attending the meeting,
please stop by to review a variety of Fixed
and Removable appliances that we will
have on display. This will include our new
MARA appliance, Lingual Indirect Bonding
service and design variations of the Herbst.
Paula and Max will be traveling throughout
the regions over the summer months attending
programs by Dr. Hilgers, Dr. Mayes and
Dr. Dischinger. Please feel free to contact Patti
Dodge should you be interested in having
them stop by your office – if they are in your
area, they would welcome the opportunity to
review your current appliance designs.
The response to the MARA article has been terrific – this
alternative functional appliance is quickly becoming known
as a Fixed Twin Block® without acrylic. One of the most
frequently asked questions concerns the archwire assembly.
We have found that headgear and lip bumper tubes are
generally not required and most of our input in this regard
is to omit them from the standard design. Future MARA
appliances will include a less bulky single tube designed
in either .018 or .022 slot sizes which will be used as our
“standard” if no reference is made on the individual
prescription form.
14-20
May
AAO Meeting – Dallas
3
5
15-19
JUNE
Dr. Hilgers – San Francisco
Dr. Hilgers – St. Louis
Midwest Regions
6-10
13-18
31-Aug. 1
10-13
24-27
JULY
Montreal
Los Angeles
GORP – Ann Arbor, MI
Max Hall & Paula Allen
travel around the country
representing AOA, attending numerous study clubs,
society meetings and continuing education courses.
Combined, they have over
40 years of experience in
the laboratory business and
are available to speak at
your local meeting.
AUGUST
Chicagoland area
Rochester/Buffalo
Other comments and questions…
“Can I adjust the upper elbow?” Yes, we will return a special
“torquing tool” with your first case to aid with adjustments to
the elbows.
“Can an expander be added to the upper appliance?” Yes,
but keep in mind that the upper elbows must be distal to
the lower unit in order to prompt the jaw into a corrected
Class I position. If more than 4-5mm of expansion is required,
expansion should be be accomplished prior to deliver of
the MARA.
“How can I advance or reactivate the MARA?” Every
appliance includes advancement bushings which easily slip
onto the upper elbow.
Remember, your first case will include the “Torquing tool,”
additional elbows and advancement bushings.
Take 25% Off Your First
Hilgers PhD Appliance
• Complete the information in the space
provided.
• Enclose this coupon in the shipping box
along with the case and send to AOA
Laboratories, Attention: Patti Dodge.
• Shipping boxes and prescription forms
can be obtained by calling Patti Dodge
at AOA at 800-262-5221.
Name
AOA Customer Service Line
800-262-5221
Address
Phone
The Hilgers PhD
T
he advent of TMA™ wire springs used in conjunction with acrylic nance button type appliances
to distalize molars has been a wide spread clinical
success. The evolution of this appliance as introduced by Dr. Jim Hilgers has included the addition
of “locking wires” soldered to the molar bands
(T-Rex appliance) so the appliance can act as an
expander prior to molar distalization. A new
approach utilizes a hygenic type RPE screw without
any palatal acrylic. The TMA springs are seated
into sheaths which have been laser welded to the
palatal side of the screw body. Traditional spot welding may not be
durable enough to withstand the forces created by the TMA springs.
To have AOA fabricate the PhD, forward an upper model in a good
quality plaster or stone with molar bands seated. AOA will provide
the lingual sheaths. Allow approximately 5-7 in-lab working days
for fabrication.
The PhD appliance is securely
anchored to the patient’s teeth by
first bicuspid bands when possible
and bondable rests on the occlusal
surfaces of the second bicuspids or
second deciduous molars. Expansion
is gained before the molars are distalized. Due to the unique properties of
TMA the springs can be preactivated,
inserted into the lingual sheaths
on the molar bands and held until
the “locking wires” are cut after
transverse width has been gained.
aoa customer service line – 800-262-5221
WEBSITE – www.ormco.com/aoaapps.html
P.O. Box 725
Sturtevant, WI 53177
AOA is a subsidiary of the Ormco Corporation